The Culture Question

There’s a saying we frequently use at Mercy. I’ve also heard it used in other organizations with variations of the same words: “Culture eats strategy for lunch.” 

That saying, originally attributed to Prof. Peter Drucker, the man many would say invented business management in the latter part of the 20th century, essentially conveys the idea that no matter how much a group might want to accomplish together, the way they treat each other will be of far greater importance in determining what they’re ultimately able to do. And while Prof. Drucker certainly deserves his place in history for his business insights, it was Mercy foundress Catherine McAuley who observed nearly 100 years before Prof. Drucker’s birth that, “who we are together is more important than anything we will ever do.” 

It’s a rare moment of clarity when business and religious leaders come to the same philosophical conclusion like this. As such, it seems worth taking some time to think more deeply about what this means within our own organization. It’s a question of culture. 

We obviously have strategies to improve patient satisfaction, co-worker engagement and financial performance. Leaders throughout our organizations spend a lot of their time thinking about those three issues and what can be done to influence them. But do we have the culture within our organization to execute those strategies? It’s not an easy question to answer. After all, it’s difficult to see the picture when you’re inside the frame. Further, one’s perspective changes depending on the vantage point within the picture. Even coming up with an acceptable definition of culture isn’t exactly straightforward, although one I particularly like is, “It’s what happens when the boss leaves.” Said differently, it may be as simple as how we feel about the people in our organization. 

So one way or another, we have a culture, and there’s little doubt that it’s the culture we deserve – one that we have behaved our way into. Describing it is important as it says volumes about who we are. Perhaps equally important is the expression of our culture to the world outside of Mercy. That expression is known in advertising and marketing circles as our brand and it’s nearly impossible for an organization’s brand to fall far from its’ cultural tree. Thus, whatever we believe our culture to be has a natural resonance in our communities and with our patients. Surely they do not see anything different in us than we see in ourselves. 

The poet Maya Angelou once wrote, “I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” I’m curious when you go home to your families, what feelings do you take with you about the people you work with? In other words, how would you describe our culture? Let me know your thoughts. Email me at alan.scarrow@mercy.net.

Motivated Reasoning

In the field of organizational behavior, there’s something known as motivated reasoning – that’s when someone seeks explanations that confirm their beliefs and ignore everything to the contrary. For example, both before and after Apollo 11 landed on the moon in July 1969, the International Flat Earth Society proudly denounced the whole venture as a hoax. No amount of NASA film, television coverage, Neil Armstrong and Buzz Aldridge testimony - not even 47.5 pounds of moon rock could persuade them to believe otherwise. It was, in their minds, a myth the U.S. government perpetuated to cover up a yet-to-be-determined evil scheme.

Regardless of your feelings about the International Flat Earth Society, they were certainly not the first, nor the last, to engage in motivated reasoning. Throughout history, seemingly rational people have used motivated reasoning to explain myths. For example, the Viking warriors wore horns on their helmets, sharks don’t get cancer and tomatoes are vegetables (all not true by the way). One myth that invoked my own youthful motivated reasoning was the notion of a genie in a lamp – that somehow a very small 2,000 year-old magic woman could live in a bottle, reappear outside the bottle looking as a youthful, normal-sized Barbara Eden, and be able to provide the owner of the bottle with anything imaginable.

Laugh if you’d like but there were five seasons of superbly acted reruns to persuade a certain kindergartener of the possibility that even though he seemed small, there was a way to gain some control over the big world.

But eventually the kindergartener grows up and magical thinking is set aside in favor of that which is rational and determined. Still one can’t help but have fleeting moments when the thought of a genie’s magic would be...well, very helpful. A moment thinking, “if only…” and then a magical, irrational idea to follow. If only spinach tasted like apple pie…if only I knew then what I know now…if only Miami Beach was next to Osage Beach.

In the spirit of motivated reasoning and magical thought, I ask you to imagine that for one day there is a Mercy genie who could grant you a single wish. The wish can only happen within our hospitals and clinics and must make your job or our Ministry better in some way.

I'll help you get started. “If only…” Email me the rest at alan.scarrow@mercy.net (unless you are a member of the International Flat Earth Society in which case you can send me an encrypted letter – just to be safe).

What is an Excellent Community?

Those of us who spend time in the hospital have likely seen the addition of a feature from the automobile manufacturing floor to a number of patient care and support areas. The lean production process derived from the Toyota Production System has been adopted by a number of leading health systems including ours. 

The lean process is aimed at focusing co-worker time and energy on things that add value to our patients and reducing everything else. The “lean board” is a running scorecard for how we’re doing at fulfilling that principle and is updated each day in a huddle with team members. This board is organized with the five areas of excellence our organization is focused on: clinical, service, cultural, financial and community. Even if you’re not familiar with that list, the first four probably seem fairly obvious and straightforward. One would hope that any health system would aspire to have excellent clinical outcomes, an exceptional patient experience, an engaged group of co-workers, and to fulfill their mission while achieving financial profits to sustain the organization over the long term. 

But what does an excellent community look like and how does a health system make it more excellent? If you look closely at the lean boards, you’ll see the difficulty in answering that question. The “community” portion of the board is often blank. 

Here’s what we know: Communities with excellent health have low rates of poverty, heart disease, cancer, stroke, hypertension, COPD, diabetes, obesity, asthma and low birth weight babies and a high percentage of people with health insurance. Health insurance is a key driver of health status as lack of insurance is a primary barrier to primary and specialty care and other health services. Greene County is 2 percent higher than the rest of Missouri’s adult uninsured rate and roughly 36,800 adults without health care insurance. 

Here’s what we don’t know: How does our organization make an impact on those metrics? By growing the number of patients we care for, we’ll be able to create some new jobs but even the most optimistic would find it unrealistic for us to make a meaningful impact on the region’s poverty. Similarly many of the diseases listed above such as COPD, obesity and heart disease are the result of behavioral habits made by individuals. Even with our most idealistic glasses on, it’s hard to envision a health system capable of reaching into people’s lives to affect years’ worth of habits and decision-making. 

Which leads to this. We can’t do everything, but can do something, and we shouldn’t let all that we cannot do interfere with what we can. When we look at that blank community space on the lean boards, what should we fill it with? What should we be doing for our community to make it more excellent? I am interested in your thoughts. Email me at alan.scarrow@mercy.net.

Complex and Opposing Thoughts

F. Scott Fitzgerald, author of The Great Gatsby and considered by many to be one of the greatest writers in American history, has a quote that I’m reminded of fairly frequently:

“The test of a first-rate intelligence is the ability to hold two opposing ideas in mind at the same time and still retain the ability to function.”

It’s debatable whether it takes “first-rate intelligence” to hold opposing thoughts, but there’s no doubt that each one of us takes in all the information life throws at us each day, and then we try to create simple rules that make sense of the complexity that surrounds us.

When we generalize, we’re trying to make things more shallow and superficial. Even those of us who have chosen to specialize in one particular area have the same desire for simplification. We want to believe that things outside our specialty must follow rules similar to that which govern things inside our specialty. Either way, the desire to simplify ignores the complexity and nuance that makes up the world around us.

This desire has plagued science for generations. The first scientists of the 17^th and 18^th centuries had to solve simple problems such as what forces were at work when a cannon ball fell to earth or why the earth rotated around the sun. Later in the 19^th century came the challenge of making reliable predictions about seemingly unpredictable things like the movement of gas particles in a vessel or the transfer of heat from one medium to another. But the problems of the last century are complicated and defy simple rules and generalizations; things such as how to pull oil from rock shale miles under ground, understanding how our cells age or how our environment affects our bodies. These are problems that have and continue to require thousands of the brightest minds working millions of hours on ideas that are complicated, nuanced and bring together people with perspectives that are often directly opposite one another. This is science in 2015, and no branch of science demonstrates any more nuance and complexity than medicine.

Here’s an example. Today, for our organization to sustain itself, we must do two things simultaneously that seem at odds with one another. We must grow and reduce our costs and do so in an environment that is extremely complex. Growth is necessary for us to reach an economy of scale and maintain a full complement of sub-specialty care that our 459,000 patients need. At the same time the government, insurers and companies that pay for our services have shown us that we must lower our costs without compromising quality of the care if we expect them to choose Mercy as their provider. Meanwhile we must make certain that our 11,000 co-workers are paid competitively; and have opportunities for growth and personal accomplishment; and make sure we are in compliance with federal, state and specialty certification; and make sure our quality of care doesn’t slip; and reinvest in our hospital and clinic infrastructure; and come up with innovative ways to provide better care; and support our community with time and philanthropy; and well, you get the idea.

It’s difficult, complex and nuanced, but at the same time exciting, rewarding and filled with opportunity. With all that we have done and all we have yet to do, I believe if Mr. Fitzgerald was alive today and came to visit us, he would look around and say, “These are people with first-rate intelligence.” It is an honor to serve with you. 

Overcoming Adversity

Below is my most recent discussion as part of a Leadership Development series.

Respect and Trust

Last fall I attended a meeting where a talk was given by music composer Philip Glass. As he discussed his career and collaborations with various musicians, he made this provocative observation about those that turned out to be most successful.  “The key to a successful collaboration is trust. Not respect, but trust.  Trust is much harder than respect.”

I think Mr. Glass is on to something.  Most of us tend to give respect liberally because it is not a limited resource.  For example, we feel respect for people we admire because of their abilities, skill, or achievements.  Conversely, those we are not so fond of can still invoke our respect because of their position or the authority they possess. We can even have respect for inanimate things like the power of technology or laws that we need to comply with. 

Trust is different.  We can’t trust things like laws or technology because those things don’t trust us back.  The only thing that can be trusted is another person. Trust is holistic, a collection of feelings that culminate in how we regard an individual or group.  It binds our relationships together and grows only with continued use. 

The trust we have in someone is comprised of our impressions of their character and competence.  Surprisingly, it doesn’t take long for us to create those impressions.  Several studies have shown that people can size up competence and trustworthiness in as little as a quarter of a second based on appearance alone.  Of course more accurate impressions evolve over longer periods of time and with more experiences.  We trust people who trust us, who we perceive to be driven by something other than self-gain, that exhibit willpower and self-control, that get the results we need, and that communicate to us with clarity and resolve.

All of these trust factors play out in our organization every day.  Each of us has an opinion of how much we trust the leaders of the Ministry, our leaders in the Springfield Communities, the people we report to, or the people we work with.  That opinion is dependent on how we are kept in the know, the tolerance and forgiveness we receive for the mistakes we make, the credibility of the words people use, the reliability of their actions, and their openness to our influence.  We may respect their authority or who they are, but trust is built on experiences with them, how we think about them when they are not in our presence. 

You may have a lack of trust in various groups or people within our organization.  It is understandable.  We have gone through tremendous amounts of change during hard times.  Several difficult decisions were made that created disagreement and at times a loss of control.  Of course apologies and reasons for these events don’t forge trust, only time and new experiences can do that.  But trust is necessary.  It has been said that every government must have food, weapons and trust.  If it can’t provide all three, weapons should go first, then food.  Trust must be guarded to the end.  Without trust we cannot stand.  As it is for governments, so it must be for us.  We must rebuild trust that has been lost and become better and stronger in the process of doing so.

Mr. Glass was right.  Trust is much harder than respect but we are not helpless to regain it.  Please help us.  I respect the work that you do and trust that you can help move Mercy forward. You may have ideas I need to hear. If so, email me or reach out on Twitter at @DrScarrow.

Talent Development

Below is my most recent discussion as part of a Leadership Development series.

The Hard Thing About Hard Things

By the time this is published, most or all of you will have heard or been affected by the recent reduction in force. Across Mercy about 350 individuals, more than 100 in the Springfield Communities, have had their positions eliminated. Another 100 have kept their jobs but had their management positions reduced. Many of you have heard the reasons for these actions. Continued implementation of cuts in the Affordable Care Act, cuts in Medicare reimbursement, a switch to value-based payments, and lack of Medicaid expansion in Missouri are among many reasons that the Springfield Communities will see at least $30 million less revenue in the coming year, despite taking care of more patients.

Less revenue forces us to find ways to reduce our costs if we are going to maintain the quality and breadth of service our community expects from us. Given that approximately 60 percent of all our costs are wages and benefits, it is no surprise that part of that cost reduction results in a loss of co-workers.

As this financial reality became clearer and it became apparent what actions we would need to take, our priority became placing the brunt of the reduction in force on management and doing everything we could to augment salaries and additional manpower to front-line positions – to the ER, hospital floors and clinics where patients are cared for. Thus the jobs affected in the Springfield Communities have primarily been vice presidents, directors, managers and supervisors. Some of these individuals have been with Mercy for many years and dedicated their entire professional careers to our organization, which makes it disheartening for all of us. That, of course, is the hard thing.

Decisions about cutting costs and making our organization sustainable start on pieces of paper, analyzing numbers, reviewing metrics…and then that time ends. Numbers turn into positions which turn in to people. People we know and work with and care about. People who have families that rely on them, with bills that have to be paid, and dreams that now have to be reimagined. That’s when it gets real. That’s when the emotions of the moment become our reality and the numbers and metrics that led to them seem distant and hollow.

For those who have not been directly affected by the reduction in force, I suspect some will continue to have fears. Perhaps some will fear they could be next. Perhaps some question our commitment or ability to sustain the organization. I cannot quiet all those fears. The fact remains that these are challenging times for health care. But while this moment may be difficult, we will face these moments together and overcome our challenges. Perhaps it is comforting to know when times get hard that there have always been hard times. Through each of those times we have gotten better, learned how to work smarter and remembered how we were resilient. One day when we inevitably face another difficult time, we will no doubt look back on this moment and recall the sadness of what it is like to do hard things. Yet as we recall the sadness, we will also know that when we had to, we were able to do hard things – the hard things that allowed us to continue in the service of others. We will be mindful to let our hopes, not our hurts, shape our future.

I thank each one of you for your continuing service and resilience in this moment. If you have questions about the reduction in force or want to express your thoughts to me directly, please email me at Alan.Scarrow@mercy.net.

Leadership Insights

There’s a radio talk show host who’s known to use a simple phrase that carries a lot of heft. “Words mean things,” he often says in response to those who take seemingly plain words and interpret them in creative ways. He’s right in a way – words do mean things. They must have some common, easily understandable meaning in order for us to communicate clearly with one another. But the English language is nuanced, and there are some – politicians, lawyers, comedians and advertisers come to mind – whose job it is to parse the language and amplify (sometimes exploit) the nuances to make their points. Words do mean things, but they may not mean the same things to everyone.

This is one of the reasons it’s so important for organizations to write mission, vision and values statements with as much clarity as possible. Show me a list of values written by an organization’s attorneys, and I’ll show you an organization that’s confused. Values must be written from the gut – by the people who can’t separate their own identity from that of the company. They’re the ones who know what the organization was meant to be, what it is and what it hopes to be.

Thankfully such is the case with Mercy. The Sisters of Mercy wrote a list of values that have words that are quite common. They aren’t unique to Mercy or Catholic health care or even non-secular health care. Dignity, Service, Stewardship, Justice and Excellence could be the values of any organization – even those outside of health care. But they have clarity. They mean things.

I would ask you to think about one of those values in particular. Excellence in Mercy’s tradition is defined as giving “only the best for those entrusted to our care.” From a leadership perspective, the challenging thing about excellence is that it can’t be ordered. We can require people to be satisfactory, and we can correct people or in rare and extreme cases even dismiss people if they’re not satisfactory. But no one can make someone else be excellent. That is their choice. As a leader in this organization, the best I can hope to do is to inspire or influence others to choose to be excellent, but that’s where my influence ends and their autonomy takes over in full.

As you go about your busy workday at Mercy, I’d like to know what inspires you to choose to be excellent? What pushes you in the opposite direction toward mediocrity? I’m interested in your thoughts. Please email me at alan.scarrow@mercy.net.

Diversity

Recently my neurosurgery colleague Brian Ragel and I went to India on behalf of the Congress of Neurological Surgeons to teach some surgical courses to Indian neurosurgical trainees.  On our way to the city where the courses were held, we stopped at a tea plantation in the mountains of southern India where I snapped this picture.  While this picture of Dr. Ragel against one of the many mountains where tea bushes have been planted for centuries may look like a typical “let me show you where I went on vacation” photo, the story contained within its four corners is quite interesting.  Three thousand years ago, people in China started drinking tea, a step that coincided with drinking boiled water that, coincidentally, killed disease-bearing microorganisms.  Tea bushes grow best at high altitude in a warm, wet climate.  Since the mountains of southern India are close to the equator, it is an ideal place for growing tea making India one of the largest tea producers in the world.  However, tea is not native to India.  According to our tour guide, tea seeds were originally brought to India by prisoners of war from China.  While the tea thrived most of the time, some years the climate was too wet and the tea bushes suffered.  To solve that problem, Australian eucalyptus trees were planted because their deep roots soaked up excess water.  Of course none of this mattered until there was a large market to sell the tea which happened when the British invaded India, loved the tea and began vigorous cultivation and exportation of cargo ships full of tea to millions of caffeine starved Europeans.  Thus in the picture you see Dr. Ragel, a man of European descent, at an Indian tea plantation, enjoying the harvest of a Chinese plant whose growth is enabled by Australian trees.  Makes the world seem quite small doesn’t it?

As I was looking at this picture I began thinking about how diverse and connected life in Springfield, Missouri is with the rest of the world.  Within my own group of eight neurosurgeons, we have individuals that are one generation or less removed from Iran, Korea, Pakistan and Nigeria.  On the small cul-de-sac where I live we have many of the world’s great religions represented – Protestants, Catholics, Hindus, Muslims, and Mormons - all within throwing distance of each other.  Even a simple can of Coca-Cola that you may have on your shelf at home in southwest Missouri is contained in an aluminum can from Western Australia, filled with syrup based on a recipe from Atlanta, Georgia that calls for Mexican vanilla, cinnamon from the inner bark of a Sri Lankan tree, coca leaf from South America (processed in a plant in New Jersey to remove the cocaine), and combined with red kola nut from the African rain forest.

Each of us has these stories that connect us to others.  We need them.  The diversity of opinion, background and perspective opens our minds, stimulates new ideas, makes for more innovation, and powers our growth. I’ve shared some of my own stories of diversity, I am interested in yours.  How do you find yourself connected to the rest of the world?  Email me at alan.scarrow@mercy.net or follow me on Twitter: @DrScarrow.

Truven Award

Earlier this spring, the Mercy Springfield Communities leadership team was notified that our Springfield Hospital was named a recipient of the prestigious 2015 Truven Health Analytics Top 100 Hospital Award. This is a tremendous honor for our organization and coworkers. 

For the 22^nd year in a row, Truven analyzed 2,787 acute care hospitals in the U.S. using publicly reported Medicare data on Medicare including information about mortality, complications, patient safety, readmission, length of stay, expenses per discharge, and operating profit margin.  Hospitals were then grouped together in five categories: major teaching, teaching, as well as large, medium and small community hospitals.  Mercy Springfield was named one of twenty winners in the large community hospital category and was one of only three hospitals in the state (along with Mosaic Life Care St. Joseph and BJC West County) and the only one in southwest Missouri.  Hospitals cannot pay to be named a Top 100 Hospital and Truven does not accept anything other than publicly reported data making it an objective and extremely reliable assessment of a hospital’s true performance.  Mercy Springfield scored in the top 10% in the country for lowest complication rate and in the top 25% for mortality, length of stay, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and operating profit margin.  

To put in perspective the achievement of being named a Top 100 Hospital, if all U.S. hospitals attained the same quality, safety and cost metrics as the Top 100, the nation would have 126,500 fewer patient deaths, 109,000 fewer patient complications and $1.8 billion of savings in inpatient costs.  Even more context can be gained by looking at the performance of other hospitals in the U.S. during the same time period.  More than 90% of all hospitals had no change in mortality, complications, patient safety, and length of stay; 86% had no change in their profit margin and 76% reported no change in HCAHPS scores.  Perhaps most remarkable is that only 2.6% of all hospitals in the U.S. reported a reduction in expenses per discharge.  By comparison, in the first 7 months of the current fiscal year alone, Mercy Springfield has been able to reduce expenses per discharge by 4%.

Reading the substance behind this award and now fully understanding how substantial our results are compared to the rest of the nation makes sharing this news even more fun.  We look forward to communicating further about this award and more importantly honoring you, our coworkers, for making it happen.  Each one of you creates a real difference in the lives of your patients.  Perhaps that type of feeling is hard to quantify and it may not get counted like a lot of other things when it comes to award time, but it matters – a lot.  And always will.  Thank you for all you do.